I am looking for research on best practices for treatment of methamphetamine exposed infants in order to create a bundle for my unit. We currently use Eat, Sleep, Console for our opioid exposed infants, but we want to differentiate between the two and create a pathway for the stimulant exposed infants. A quick overview of literature turned up almost nothing, so I would trully appreciate any help that can be provided.

We still use ESC as our baseline assessment, but will commonly use clonidine in these infants as a starting point, depending on how their symptoms are manifesting.

@tvedder do you have a typical dosing scheme for clonidine, or do you treat "as needed" based on changes in Finnegan scores? What other pharmaceuticals would come in as 2nd line tx?

I admit I only have very limited experience from infants with non-opoid abstince. As I recall from one experience some years back, we also primarily focused on non-pharma strategies and oral clonidine in standard doses of 2 - 4 microgram/kg (x 4 - 6) (but I think we also used small x-a's of midazolam, on top)

While not methamphetamine, I recently took care of an infant whose mother was treated with daily doses of lisdexamfetamine, paroxetine, pregabalin, lamotrigine, oxazepam, zopiclone, and a couple of other medications. The child suffered from meconium aspiration syndrome and was showing signs of developing PPHN, so we needed to avoid withdrawal symptoms. Since there was no opioid exposure, we looked at using phenobarbital instead, which is recommended as a complement to morphine in polypharmacy according to the Australasian Neonatal Medicines Formulary. https://www.anmfonline.org/wp-content/uploads/2024/07/Phenobarbital-Phenobarbitone_ANMFv3.1_20270731.pdf

Maybe @Dotan S has some good input when it comes to different pharmaceutical options (and I'm sorry Dotan, but this time we said no to breastfeeding due to complicating factors).

Thanks, Gustaf.

I'm afraid I do not have much to contribute on pharmacotherapy for newborns exposed to methamphetamines in utero, as the literature is indeed scarce (see this Canadian report from 2019 titled: "Treatment of Neonatal Abstinence Syndrome due to Crystal Methamphetamine: A Review of Clinical Effectiveness and Guidelines", which turned up virtually nothing) and I have no experience with such cases.

It seems that non-pharmacological treatment is indeed the mainstay in these cases, as evident in the Consensus Guidelines for Management of Neonatal Opioid Withdrawal Syndrome (NOWS) & Drug-Exposed Infants, so evaluation according to ESC seems appropriate. In addition, there are no available data on the pharmacokinetics of methamphetamine in newborns, so predictions of clearance and duration of observation for clinical effects cannot be made. Overall, clinically significant plasma levels may not persist beyond ~48 hours (cf. data in adults), but delayed metabolism due to immature liver function MAY contribute to higher/longer exposure in the (premature) neonate. As mentioned, no substantial evidence is available.

So apparently we are left with ESC and monitoring for clinical effects, while keeping an eye on use patterns by parent(s) and signs/evidence for concurrent exposures to other substances (as these may typically occur and require attention as well).